Welcome to my blog, a place to explore and learn about the experience of running a psychiatric practice. I post about things that I find useful to know or think about. So, enjoy, and let me know what you think.

Saturday, January 11, 2014

A New Low

Just when you thought it was safe to have health insurance... I mean, there's the Affordable Care Act, that at least makes it impossible for insurance companies not to insure you if you have a pre-existing condition, even if there are tons of problems with the Act. And there's the Mental Health Parity thing. You'd think that would provide some protection.

Skeptical by nature, I assumed insurance companies would come up with new and interesting ways to bite. And they have not disappointed.

A patient of mine submitted a claim a while back. A couple months later, when it wasn't reimbursed, the patient followed up, and sure enough, the insurance company had no record of the claim. (I happen to know that the claim was submitted properly). The patient re-submitted the claim, and the insurance company's response was that it was submitted too late, so they wouldn't reimburse. (I think there's a similar joke about a dry cleaner).

The patient appealed. Forms were filled out. Phone calls were made. More forms were filled out.
And now, another form needs to be filled out to "justify" out-of-network services, even though the appeal is about the supposedly late submission of the claim. My job, in this, is to cite two examples in "the literature" explaining why the patient requires out-of-network services.

When I learned this, my first thought was, "How am I supposed to come up with that?" But after some thought, I decided there are a couple arguments to be made, characterized by certain lines of inquiry.

1. Continuity of Care-do patients fare better when they don't switch providers?
2. Therapeutic Alliance-related to continuity of care, but also different, since it is possible to continue care with someone with whom you have a poor therapeutic alliance.

And there's an uncomfortable "3", which is, "Do patients actually have better outcomes with out-of-network providers, and if so, why?"  Related to this is, "Are there discernible differences between providers who accept insurance, and those who don't?"

So I thought I'd make lemonade and post about researching these ideas. I'd prefer sparkling limeade with coconut, but we're talking insurance companies here.

I searched, "continuity of care psychiatry", and got a bunch of links. And then I got more links from those links. Some of the articles were about defining the meaning of continuity of care. Others seemed to just assume that continuity of care was a good thing.
There was a reference to the National Service Framework for Mental Health, which is a 2001 Department of Health document from the UK, too long for me to read in full, but the source I got it from (can't remember) claimed that it recommends continuity of care as essential.

Here's more:

Intensity and Continuity of Services and Functional Outcomes in the Rehabilitation of Persons with Schizophrenia

Clients who...had fewer gaps in service delivery achieved greater rehabilitative improvement in social, work, and independent living domains and had fewer days of hospitalization.

Another article that seems critical is:

Tessler RC. Continuity of care and client outcome. Psychosocial Rehabilitation Journal 1987; 11(1):39-53.

Unfortunately, I couldn't track it down online. Not even the abstract.

There's what looks to be a not-quite-on-my-target paper, Continuity of care in mental health: understanding and measuring a complex phenomenon, but the bibliography is promising.

I found this article in the "continuity of care" search:

Therapeutic Alliance and Psychiatric Severity as Predictors of Completion of Treatment for Opioid Dependence

among patients with moderate to severe psychiatric problems, less than 25 percent with weak therapeutic alliances completed treatment, while more than 75 percent with strong therapeutic alliances completed treatment...In this patient subgroup, a strong therapeutic alliance may be an essential condition for successful treatment.

Next I searched, "therapeutic alliance and treatment outcome."

I found this article in JAMA Psychiatry:

The Role of the Therapeutic Alliance in the Treatment of Schizophrenia
Relationship to Course and Outcome

This study examined the relationship of the therapeutic alliance to the treatment course and outcome of 143 patients with nonchronic schizophrenia... Results showed that patients who formed good alliances with their therapists within the first 6 months of treatment were significantly more likely to remain in psychotherapy, comply with their prescribed medication regimens, and achieve better outcomes after 2 years, with less medication, than patients who did not.

And this one from J consult Clin Psychol:

The relationship between the therapeutic alliance and treatment outcome in two distinct psychotherapies for chronic depression.

This study tested whether the quality of the patient-rated working alliance, measured early in treatment, predicted subsequent symptom reduction in chronically depressed patients...A more positive early working alliance was associated with lower subsequent symptom ratings in both the CBASP (cognitive behavioral analysis system of psychotherapy) and BSP (brief supportive psychotherapy),...p < .001.

Then there's the psychoanalytic literature. There are a ridiculously large number of hits for "therapeutic alliance" and "analytic dyad", but they're mostly about the meaning and development of those elements. It's axiomatic that a good alliance is a necessary part of any treatment.

I also searched "discontinuity in psychiatric care", and mostly I got measurements-e.g. how many new patients in a clinic drop out of treatment. They didn't seem to address the problem of what happens to patients when they stop treatment, or switch treatment providers.

I searched:
"patient outcomes in psychiatric clinics with frequent change in providers"
"Do psychiatric patients get worse when they switch providers"
"Do psychiatric patients drop out of treatment when they switch providers"

Nothing came up that seemed to address what typically happens in an outpatient clinic, where there's resident turnover every year, and what that does to patients, which is what I was hoping to find with those searches.

Now on to point "3", patient outcomes with out of network vs. in network psychiatrists. That search came up with things like, "benefits of antidepressants" and "Providers are responsible for the correct submission of claims", under OUTreach...Network.

One thing we do know is that fewer psychiatrists than doctors of other stripes accept private insurance:

The percentage of psychiatrists who accepted private noncapitated insurance in 2009-2010 was significantly lower than the percentage of physicians in other specialties (55.3% ...vs 88.7% ... P < .001) and had declined by 17.0% since 2005-2006.

But what are the differences between shrinks who decide to join an insurance network, and those who don't? And whose patients do better? I wonder if the study's been done. And if it hasn't, someone should do it, because the results are not simply academic.


  1. Interesting. You focused on continuity of care, and not on why the patient needed to go out of network to begin with. I wrote a post back in 2007 about why shrinks don't take insurance (an oldie but goodie?). But if there are out-of-network benefits, I don't believe the patient's policy says "must justify out-of-network care." The insurance company is giving you the run-around. Tell the APA about this, maybe the parity folks, do they make every doc justify out-of-network care if they submit claims "late" after they've been lost?

    1. I tried to find the 2007 post on Shrink Rap, but I don't know how to access the archives. Do you have a link to it? I'd like to read it.
      I think you're right, this should be reported.
      Maybe to the APA or parity people, but I'm also thinking Better Business Bureau. It's really about fraudulent business practices.